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PubMed2003

Varus/valgus alignment of the femoral component in total knee arthroplasty.

The position of the femoral component in 362 total knee replacements was assessed radiologically. A subgroup of 32 knees, 18 of which had perfect alignment and 14 with imperfect alignment underwent CT scout scans of the femur from which the mechanical axis of the femur could be measured. Radiologically 92% of all components were implanted within 3 degrees of the target value. There was close correlation between the CT and X-ray measurements in the subgroup. Deviation from the mechanical axis was 1.16 degrees (range -2.5 to +2) in the perfectly aligned knees, validating both surgical technique and radiological assessment. Causes for inaccuracy in femoral placement and future likely developments are discussed.

Arthroplasty, Replacement, Knee↗

PubMed2004

Reviewing knee osteoarthritis--a biomechanical perspective.

Osteoarthritis (OA) is the most common form of arthritis and is a major cause of disability in people aged over 65. Despite the major socioeconomic burden imposed by OA, the aetiology of this condition remains unclear. Although controversial, several metabolic factors have been implicated in the disease pathogenesis. Nevertheless, no unequivocal systemic risk factors for the onset or progression of OA have been identified. Recently, there has been a growing interest in the biomechanical factors associated with the pathogenesis of OA. This review aims to discuss several of the more pertinent biomechanical and neuromuscular factors, such as the knee adduction moment and muscle strength, that are becoming increasingly accepted as factors that contribute toward the pathogenesis of knee OA.

Biomechanical Phenomena↗

PubMedDate not supplied

In vitro effects of osteotomy angle and osteotomy reduction on tibial angulation and rotation during the tibial plateau-leveling osteotomy procedure.

OBJECTIVE: To determine the effect of osteotomy angle, reduction technique, and tibial plateau rotation angle on angular and rotational limb deformities. STUDY DESIGN: Geometric comparison using bone models. METHODS: Rotational osteotomies were made in the proximal metaphysis of artificial tibias at 0 degrees, 10 degrees, 20 degrees, -10 degrees, and -20 degrees from perpendicular with respect to either the proximodistal and craniocaudal tibial axes. Negative-numbered angles represented osteotomies made from distal to proximal or caudal to cranial. Changes in tibial angulation and torsion were measured using a 3-dimensional digitizing instrument at tibial plateau rotation angles from 0 degrees to 30 degrees at 5 degrees increments. Two osteotomy reduction techniques were used: complete osteotomy reduction and alignment of the medial cortex. The mean of 5 measurements of torsional and angular tibial deformity for each of the 9 osteotomy orientations in each reduction technique group was obtained. RESULTS: All had increasing angular and rotational deformity as tibial plateau rotation angle increased. In the medially aligned cortex group, all tibias had valgus deformity, and 8 of 9 tibias were internally rotated. In the reduced osteotomy group, minimal angular deformity was seen in tibias with osteotomy variation along the proximodistal axis; however, tibias with osteotomy variation along the craniocaudal axis had angular deformity ranging from 6.0 degrees of varus deformity to 14.3 degrees of valgus deformity. Rotational deformity was affected similarly by osteotomy variation along either axis. Reduction technique had greater affect on angular and rotational deformity than osteotomy angle variation. CLINICAL RELEVANCE: These results suggest that osteotomy reduction may play a greater role in angular and rotational deformity than osteotomy angle, although extreme osteotomy angles should be avoided. To decrease the severity of deformity, we recommend that the osteotomy be made perpendicular to the craniocaudal and proximodistal axes and be completely reduced with less regard for alignment of the medial cortex.

Animals↗

PubMed2001

The effect of surgeon experience on component positioning in 673 Press Fit Condylar posterior cruciate-sacrificing total knee arthroplasties.

Component angles of 673 Press Fit Condylar (PFC) total knee arthroplasties were measured from standard short-leg radiographs. The femoral and tibial resections were performed with intramedullary and extramedullary instrumentation. The mean coronal tibial component angle was 88.59 degrees (SD, 2.28 degrees; range, 78-98 degrees ), with 17.1% having values <87 degrees and 1.9% having values >93 degrees. The mean coronal femoral component angle was 97.43 degrees (SD, 3.44 degrees; range, 84-115 degrees ), with 9.1% having values <94 degrees and 13.1% having values >100 degrees. An ideal tibiofemoral angle of 4 degrees to 10 degrees of valgus was achieved in 75.3% of patients, being <4 degrees in 18.6% and >10 degrees in 6.1%. Alignment was not significantly different between consultant and trainee surgeons. Although varus positioning of the tibial component was the commonest error, the wide range of femoral component angles signifies problems with standard intramedullary femoral guides.

Arthroplasty, Replacement, Knee↗

PubMed2001

Primary total knee arthroplasty in the valgus knee: creating a balanced soft tissue envelope.

Lateral tissue releases in valgus total knee arthroplasty frequently produce asymmetric flexion-extension gaps and ligamentous instability. This study compared 2 lateral-release sequences and quantified the effects of sequential lateral capsular ligamentous structure release. One knee from 7 paired specimens was released according to a 4-step sequence: posterior cruciate ligament (PCL), ibiotibial tract (IT band), popliteus tendon/lateral collateral ligament (PT/LCL), and biceps femoris tendon. The contralateral knees were released according to a 5-step sequence: PCL, posterolateral capsule, IT band, PT, and LCL. After each release step, flexion and extension gaps were measured and recorded for the medial and lateral aspects. The 5-step sequence produced more symmetric flexion-extension gaps, whereas the absolute magnitudes of correction were lower than with the 4-step sequence. LCL sacrifice in both sequences produced marked lateral flexion-extension gap asymmetry.

Aged↗

PubMed2003

Tibial shaft axis does not always serve as a correct coronal landmark in total knee arthroplasty for varus knees.

Predicted postoperative knee alignment was calculated when total knee arthroplasty was performed after 1 of 3 different methods of tibia preparation in 30 osteoarthritic knees with varus deformity. In Method 1, the tibia was cut perpendicular to the tibial shaft. In Method 2, the tibia was cut perpendicular to a line connecting the center of the tibial plateau and the center of the talar dome. In method 3, tibial resection was determined with an original template so that tibial resection would be perpendicular to a line connecting the center of the resected tibial plateau and the center of the talar dome. Methods 1 and 2 caused significantly more valgus alignment than Method 3 (P<.0001). The postoperative weight-bearing ratio was in Method 1, 57.7%, in Method 2, 53.6% and 50.0% in Method 3. These results suggest that cutting the tibia perpendicular to the tibial shaft can cause valgus alignment in total knee arthroplasty for varus knees.

Analysis of Variance↗

PubMed2000

Patellar taping: is clinical success supported by scientific evidence?

Patellofemoral pain syndrome (PFPS) is a common condition presenting to physiotherapy and sports medicine practices. Despite its prevalence, the aetiology, pathogenesis, and recommended treatment remain unclear. One component of treatment for PFPS that has been subjected to scrutiny is patellar taping. This taping was designed to realign the patella within the femoral trochlea, thus reducing pain from PFPS and improving both quadriceps and patellofemoral joint function. Clinical and research findings confirm that the pain associated with PFPS is significantly reduced with patellar taping. Therefore, research has aimed at determining the mechanisms of this pain relief. The means by which patellar tape can relieve pain may provide insight into the aetiology and risk factors for PFPS, thus allowing more appropriately designed treatment regimes and preventative strategies. There is evidence to suggest that patellar tape improves patella alignment (measured radiographically) and quadriceps function (torque production and extensor moments). Evidence that patellar tape enhances the activation of individual vastii (magnitude or timing) is limited in quality and quantity, which probably reflects the difficulties inherent in measuring this complex question. There is preliminary evidence for improved knee control during gait in association with patellar tape. This paper critically reviews the studies that have examined the effects of patellar taping and makes informed recommendations for further research and clinical practice.

Arthralgia↗

PubMed2002

The inter-tester reliability of a clinical measurement used to determine the medial-lateral orientation of the patella.

An important aspect of the patellar taping technique, a common treatment for patellofemoral pain is the assessment of patellar position. The inter-tester reliability of the assessment method has been regarded as poor, as has the validity (Powers et al. 1999). The purpose of the study was to determine inter-tester reliability of a group of trained manual physiotherapists. This was achieved using a clinical measurement to assess the medial/lateral orientation of the patella and compare these findings against a known criterion valid measurement of patella position. Twenty experienced manual physiotherapists evaluated medial/lateral orientation of the patella. The findings of the clinical assessment were then compared to the position of the patella as determined through magnetic resonance imaging (MRI). The MRI and the clinical assessment were carried out on the right knee of a single subject, who was supine with the knee in 20 degree flexion with the quadriceps relaxed. Both measures found the patella to be laterally displaced. Using the clinical method the mean difference between medial and lateral measurements was 6.4 mm (+/- 3.9 mm). The MRI measure of lateral patella displacement found the patella to be displaced 5 mm laterally. The inter-tester reliability of the clinical test showed good agreement, r = 0.91 for the medial measure and r = 0.94 for the lateral measure. The agreement between the clinical and MRI measures was (r = 0.9) which was also a significant agreement. This study appears to demonstrate that experienced manual physiotherapists can reliably measure relative patella medial/lateral position.

Arthralgia↗

PubMed2004

Reliability of lower limb frontal plane alignment measurements using plain radiographs and digitized images.

This study evaluated the reliability of lower limb frontal plane alignment measures obtained from plain radiographs measured manually and digitized images measured using a custom computer software package (TheHTO Pro; Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada). Radiographic measurements used in the planning of high tibial osteotomy, including the mechanical axis angle and mechanical axis deviation, were measured on 42 hip-to-ankle radiographs on two separate occasions by two different raters (A.V.S., J.J.D.). Intraclass correlation coefficients (0.96-0.99) indicated excellent agreement between the manual and computer measurements, suggesting both methods can be used interchangeably. Although test-retest and inter-rater reliability tended to be slightly better when using TheHTO Pro, intraclass correlation coefficients were excellent for both methods (0.97-0.99). The standard errors of measurement were <1 degree for mechanical axis angle and <2 mm for mechanical axis deviation, regardless of method or rater. Based on the observed standard errors of measurement, conservative estimates for the error associated with an individual's mechanical axis angle at one point is approximately 1.5 degrees, and the minimal detectable change on reassessment is approximately 2 degrees. The error associated with an individual's mechanical axis deviation at one point is approximately 4 mm, and the minimal detectable change on reassessment is approximately 6 mm. These results suggest that manual and computer measurements of lower limb frontal plane alignment can be calculated with minimal measurement error. However, the small errors associated with both methods should be considered when making clinical decisions.

Adult↗

PubMed2000

[Late sequelae of fractures of the distal third of the forearm during the growth period].

Fractures to the distal third of the forearm are the most common fractures of the upper extremity, with the majority occurring between the age of ten and 14 years. With the exception of the rare epiphyseal fractures, they have a favourable prognosis. The present study investigates the frequency and extent of potential clinical and radiological late sequelae of fractures in the distal third of the forearm during growth. Of the patients treated at the Innsbruck University Department of Traumatology from 1980 to 1992, 220 patients of a growing age with 232 closed fractures in the distal third of the forearm were followed up. The radius alone was affected in 60% of these cases; the radius and the ulna in 40%. Fractures of the ulna alone were not present. The mean age of the patients at the time of injury was nine years (range one to 16 years) and the mean time of follow-up ten years (range five to 16 years). In addition to the patient's subjective assessment, the right and left sides were compared with regard to mobility of the wrist and rotational movement of the forearm. Based on standard X-rays, the frontal (radio-ulnar) and lateral (dorso-palmar) radial joint angle as well as the difference in the radio-ulnar plane were compared with the contralateral side. Clinical and radiological findings were summarised into an overall result. 19% of the patients reported pain in the injured wrist. Mobility of the wrist in the sagittal and/or frontal plane was limited in 5% of patients and rotation of the forearm was limited in 16% of patients. A statistically significant accumulation of limited rotation was seen after physeal fractures of the ulna ("one-way" ANOVA-test, p = 0.0033). A difference between the left and right side in regard to the frontal radial joint angle was seen in 6% of patients and a difference in the lateral radial joint angle was registered in 2% of patients. A difference in the radio-ulnar plane was observed in 37% of patients. In the presence of relative ulna-plus variance, 75% of patients complained of pain in the ulnocarpal compartment of the wrist. In these patients, dynamic magnetic resonance tomography revealed a compression of the ulnocarpal disk between the proximal carpal bones and the head of the ulna, as well as degeneration in the central portion of the disk. The overall outcome was very good in 72%, good in 19%, moderate in 6% and poor in 3% of patients. The younger the children had been at the time of injury, the more favourable were the results (chi-square test, p = 0.009). Children older than ten years of age with an angulatory deformity of more than 20 degrees and/or fragment dislocation over half of the breadth of the shaft at fracture consolidation showed the poorest results. Further factors having a negative influence on the outcome were repeated reduction manoeuvres and an additional fracture of the ulna.

Adolescent↗

PubMedDate not supplied

[Is unicondylar knee prosthesis a current possibility in primary management of varus gonarthrosis?--A prospective matched-pair study].

AIM: In the present study, we performed a follow-up investigation comparing middle-term results after unicompartmental and bicompartmental knee arthroplasties. MATERIAL AND METHODS: We used matched pairs with 18 patients in each group. The first group was treated with the unicompartmental slegde prosthesis (Type Wessinghage), the second with the cementless nonconstrained bicondylar prosthesis (Type Natural knee). The mean time of follow-up was 4.5 years. (SD +/- 0.6). The average age of the patients in both groups was 59 years (SD +/- 3). Both groups included 12 female and 8 male patients. All patients suffered from primary medial osteoarthritis of the knee. In all cases, the contralateral knee also had signs of manifest osteoarthritis. The determination and evaluation of the results of the investigation were made according to the score of the American Knee Society. We also reviewed the radiological findings concerning placement of the prosthesis, radiolucent lines, and patella position in the femoral shield. RESULTS: At follow-up examination, there were no significant differences in the knee score between the patients undergoing unicompartmental or total knee replacement. However, patients with the Wessinghage sledge tended to show better results. The mean knee score was 94.3 +/- 4.9 in the Wessinghage group and 91.9 +/- 8.3 in the Natural knee group. Evaluation of the radiographs revealed radiolucent lines in the group with total replacement. In contrast, in 7 of 18 patients with the unicompartmental prostheses we found radiolucent lines at the tibial component of 1 mm or more, which, however, did not cause clinical symptoms. CONCLUSION: Our results show, that the unicompartmental arthroplasty is still an effective method for the treatment of the osteoarthritis, especially concerning the conditions for possibly needed revisions.

Aged↗

PubMedDate not supplied

[Quantification of position-related errors in measurement of antetorsion of the femur with computerized tomography--introduction of a method for positional correction].

OBJECTIVE: To quantify the influence of patient positioning on the determination of collodiaphyseal (CCD) angle and femoral neck anteversion based on computed tomography. Description of a method for positional correction. METHODS: We evaluated the CT scans of 84 femora from 77 patients, who received individually adapted prostheses. Projected as well as real anteversion and CCD angles were determined and corrected for positioning errors using a newly proposed mathematical method, and compared to other evaluation methods. RESULTS AND CONCLUSIONS: We determined an average tilt of 4.2 degrees in the sagittal and of 9 degrees in the coronary plane, which correlated definitely with the deviations found in the graphical determination of the projected anteversion angle. This produced measurement errors of the projected anteversion angle of up to 10 degrees. Mathematically independent angles, such as projected anteversion and real CCD angle, showed only a weak correlation. This indicates also an anatomical independence of these angles.

Adult↗

PubMedDate not supplied

[Orthopedic considerations of trichorhinophalangeal syndrome type II].

INTRODUCTION: The trichorhinophalangeal syndrome type II or Langer-Giedion syndrome is regarded as a rare abnormity that is marked by a number of clinical characteristics beside multiple cartilaginous exostoses. RESULTS: The deviation of the fingers within the scope of the TRPS II that is often reported in literature can not be found in the case at issue of a now 14 year old boy. The course of disease was complicated due to consecutive axis deviation of two large joints of the lower extremities being determined by the syndrome. Due to the marked exostoses in the area of the growth plate of the left knee joint a valgus deformity developed there. It was corrected with means of a temporary clamping of the growth plate. With the increasing valgus deformity of the right ankle causing a calcaneovalgus foot deformity the osteochondroma located at the distal fibula was also removed and a temporary clamping of the growth plate was carried out at the right medial malleolus. From earliest childhood repeating cartilaginous exostoses both at the extremities and the trunk attracted attention. Also strongly developed are the facial distinguishing marks which determine the typical shape of the face. CONCLUSION: By the case of a now 14 year old boy with severe orthopedic complications considerations are made concerning therapeutic principles due to the TRPS II.

Adolescent↗

PubMedDate not supplied

[Determination of the axis after totalendoprosthesis of the knee: functional X-ray photography as golden standard].

AIM: To examine the question of which X-ray photography technique should be given preference after implantation of total endoprosthesis of the knee. METHOD: 20 patients (age 74.1; 12 men, 8 women) with total endoprosthesis of the knee (Type Sigma, PFC, Johnson and Johnson) because of primary athrosis. Postoperatively X-ray photographs of the whole leg in standing and 40 x 20 a. p. in a flat position were taken. The angles of the axis were determined and the information analysed. RESULTS: By means of X-ray photography of the whole leg we obtained the following angles: caput-collum-diaphyse 125 +/- 4.3 degrees, femur/basis of the knee 83.2 +/- 2.6 degrees, mechanical femur axis/basis of the knee 89.3 +/- 1.8 degrees, tibia/basis of the talus 89.2 +/- 2.2 degrees. With the 40 x 20 a. p. X-ray photographs we determined the following angles: femur/basis of the knee 82.3 +/- 3.1 degrees, basis of knee/tibia 92.2 +/- 3,6 degrees. Correlating the angles of femur/basis of the knee and basis of the knee/tibia were relations of 0.42 (p < 0.05) and 0.27 (p < 0.05). CONCLUSION: For gaining information about the axis of the leg under functional conditions, one should give preference to X-ray photography of the whole leg.

Aged↗

PubMedDate not supplied

[Influence of intertrochanteric varisation osteotomy on the gait of children with Perthes disease].

BACKGROUND: The purpose of this study was to investigate possible effects of intertrochanteric varisation osteotomy on the gait of children with Perthes disease. PATIENTS: Clinical and radiographic examinations and gait analysis were conducted on 50 children. METHOD: Gait analysis was conducted using the GANGAS system. RESULTS: Despite predominantly very good or good results shown by the clinical and radiographic examinations, gait analysis detected various functional deficits. CONCLUSIONS: The examinations show that for the group of patients described, gait analysis is a valuable method of recording functional deficits and early recognition of the need for postoperative, physiotherapeutic treatment, thus helping to avoid chronificating alterations of the gait and, consequently, potential secondary damage.

Bone Malalignment↗

PubMed2002

[Kinematic changes after bicondylar resurfacing knee arthroplasty].

AIM: Knee joint motion appears as a hinge movement around the flexion - extension axis. But corresponding to the rolling-sliding-mechanism and alternative models of knee joint kinematics an instant center pathway must be expected. Objective of the study was the comparison of this pathway when assessed in the sagittal plane in patients with preoperative varus or valgus deformity. METHOD: A total of 40 patients either with varus or valgus deformity (20 in each group) were examined before and 6 months after implantation of PFC(R)-SIGMA prostheses. Apart from the influence of knee joint deformity (35 degrees varus to 24 degrees valgus), a so called soft tissue ratio was investigated. Therefore the relation of thigh and femur as well as lower limb and tibia diameters was calculated and combined in one value. The examination by means of photogrammetry consisted of a standardized chair with passive knee joint movement (90 degrees to 0 degrees flexion) supported by an electric motor. The position of defined skin markers was assessed by digital camara with online transmission to PC. The instant center pathway was then evaluated applying the Reuleaux-technique based on the changes of skin marker positions. RESULTS: Results showed a dependence of the course and dimension of the instant center pathway on the extent of soft tissue ratio as well as knee joint deformity. Small values of the ratio (W = 2.9) were represented by round or oval courses of the pathway whereas increasing ratios (W = 4.0) led to triangular and slightly increased dimensions of the courses. Varus deformitywas primarily combined with an increase of the pathways dimension and in contrast, valgus deformity showed decreased pathways. In each case, dimension normalized after prostheses implantation. CONCLUSION: The instant center pathway of knee joint motion showed for both patient groups characteristic phenomen. They were clearly combined with constitutional and clinical features of each patient.

Aged↗

PubMedDate not supplied

[Correction of deformities with conventional and hexapod frames--comparison of methods].

AIM: Distraction osteogenesis for the correction of deformities with an external fixator is well established. The hexapod principle of robotic technique was invented for the Ilisarov apparatus (e. g. Taylor-Spatial-Frame/TSF). Treatment with conventional frames needs a patient-customised frame mounting. This demanding procedure is markedly reduced using this technology. The aim of this study was to analyse the value of the hexapod principle in external fixation. METHOD: The potential of a frame to correct deformities is limited by its work space. The geometry of a conventional frame is different from the geometry of a hexapod frame, which is the reason for their different work spaces. The work space of the hexapod frame is compared to the work space of a conventional frame. Important parameters for this analyses are minimal and maximal frame heights and the potential of correction. RESULTS: The minimal frame height of hexapod fixators is higher compared to conventional Ilisarov fixators. The standard hexapod frame (TSF 155 mm ring diameter) can correct 23 degrees of angulation, 36 mm of shortening, 71 mm of translation and 43 degrees of rotation without changing the telescope rods. The standard conventional frame (160 mm ring diameter) can correct 90 degrees of angulation, 100 mm of shortening, 25 mm of translation and 12.5 degrees of rotation without remounting of the frame. CONCLUSION: The different work spaces of the different frames result in consequences for their clinical application. The hexapod frame has more power to correct translation and rotational deformities than a conventional frame. Correction of extensive angulation and shortening deformities almost always needs an exchange of telescopic rods. Conventional frames are usually able to correct these deformities with the primary mounting. Because of its increased minimal frame height, the indication for hexapod constructs in child orthopaedics can be limited.

Adolescent↗

PubMedDate not supplied

[Long-term results after uni- and bilateral high tibial osteotomies].

AIM: This study compares the long-term results of uni- and bilateral high tibial osteotomies. METHOD: 94 osteotomies (72 patients) were followed for 12.7 +/- 2.4 years after osteotomy. Long-term results of 21 patients with bilateral osteotomies (42 osteotomies) were compared with 52 patients who had a unilateral high tibial osteotomy. Endpoint of survival, was defined as implantation of a knee endoprosthesis (Kaplan-Meier analysis). At follow-up clinical results were evaluated by the knee society score and X-rays were analysed for axis and grade of arthrosis. RESULTS: Out of 94 high tibial osteotomies 22 (23 %) ended 1 - 13 years later in a knee endoprosthesis. In 11 of the 42 bilateral high tibial osteotomies (26 %; after 2 - 13 years, median 8 years) and 11 of 52 (21 %; after 1 - 11 years, median 8 years) unilateral osteotomies an endoprosthesis was implanted. Kaplan-Meier analysis resulted in no statistical difference in survival between the two groups (p = 0.6517). Additionally, clinical and radiological results were equal. CONCLUSIONS: We conclude that there is no long-term difference between uni- and bilateral high tibial osteotomies and both indications can be recommended due their satisfactory long-term results.

Aged↗